Our session today featured two very powerful videos, one about Lewis Blackman and his death due to a missed diagnosis, and the other about Mrs. Morris and her catastrophic injury from a routine bedside procedure. These stories made me think of how victims of medical error, including the well-intentioned healthcare professionals involved, can often be made to suffer repeatedly after the incident by how the system responds to the error. In the case of Lewis Blackman, for his mother to have nobody reach out to her after returning home from the hospital and to not be included in the investigation of what happened to him must have added another layer of pain even beyond the devastation of losing her son. In the case of Mrs. Morris, for a young doctor to be joking and laughing with a patient one moment and then have her go into… Continue reading
In today’s session, we discussed a number of topics ranging from dealing with communication problems to establishing the importance of placing patient safety as a core value, and not simply a priority as John Nance stated. What struck me most is that although we emphasize the strength in the power of one, there lies the opportunity to synergize our collective powers of one to become a new power of a united front. When examining the aviation industry and the reasons why it successfully turned its practices around to establish validated checklists and ensure customer safety for thousands of flights every day across the globe, one can find at its core the agreement between the leadership down through the staff that safety is at the forefront of all future decisions. Changes had to be made and over time, the leadership agreed, united and came together to tackle a monstrous task. Unfortunately… Continue reading
Our group had a really great discussion about informed consent after watching “The Faces of Medical Errors… From Tears to Transparency: The Story of Michael Skolnik”.
Even though all of us agreed that the importance of informed consent has been appropriately emphasized throughout our education, many of us were unclear on the practical aspects of the “ideal” version of informed consent. A distinction that was highlighted by the film is that informed consent is a dynamic process, not a singular event, and does not merely end with the patient’s signature on the consent form. One conversation would not suffice regardless of how comprehensive it might be.
The consideration that, at any point in time, circumstances driving the patients’ decisions can change and they can withdraw their consent should remain at the forefront of caregivers’ minds.
Not only does maintaining this collaborative process prevent harmful outcomes, but it improves patient satisfaction… Continue reading
I told a colleague I would be out for a week to attend a patient safety conference, and her first comment was, “Oh, is that a particular interest for you? Patient safety?” As a student training to work with patients as a career, I couldn’t understand how any topic with the word ‘patient’ in it had the option of being an interest. Whether I liked it or not, I needed to know it and figure out how to make it an interest because it would be the main focus of my career.
From the opening remarks of the Telluride Experience, it was clear that whatever level of interest I had in patient safety prior to the conference would be exceeded as it has now consumed my thinking. It was the perfect riddle. Everything seemed to contribute to it and lack of something reduced it. Everyone needed to be aware of… Continue reading
It’s hard to be more impressed after our first day at Telluride Napa 2015. The first set of sessions spanned the gamut from stirring personal patient stories, to workable and translatable sets of tools to take home to New York, to fantastic conversations with both faculty and medical student participants.
I have to say, my favorite (and most challenging) segment so far was the impromptu exchange between our lucky guest, the mother and inspirational patient advocate, and the CEO of The Doctors Company (a malpractice insurance provider). Their remarks touched on the candid, the taboo, and the important. The tension between “CYA medicine” or “defensive medicine” and doing absolutely right by the patient will be ever-present in our clinical practice (and that’s not to mention the central role of cost-effectiveness in the equation). So to see these boundaries being hashed out by two extremely invested experts was a privilege. I… Continue reading
It was great having a session on human factors. I had a great review and also learned a lot of new things. I love data, so having all of the results from the various studies made me smile. In thinking about outcomes to look at for my project it will be important to see if I can capture how interruptions/disruptions affect communication, patient care, and patient clinical outcomes.
I also gained more appreciation and received validation for my beliefs that the patients and health care professionals must have a partnership. This relationship relies on mindfulness and we must include the family because they are the patient’s advocate(s).
This was another educational and emotional day for me at the Telluride QI/PS summer camp. The first part of the day was focused on informed consent and shared decision making. I was moved to tears watching the story of Michael Skolnik and am so thankful to his parents for sharing their story with us.
It really got me thinking about the appropriate use of the informed consent document and how poorly we often counsel and consent our patients for complex and dangerous procedures.
In Michael’s case we will never know what transpired between him and the surgeon on the day he was consented for that second procedure. But Michael is not the first nor will he be the last patient who cannot tell us whether he received and understood all the necessary information to make an appropriate decision about such an invasive procedure.
Should we as physicians be relying on… Continue reading
To err is human, and to fail to recognize our humanity is disastrous. It think this recognition is at the core of what we’re talking about this week. One of the reasons that I’ve seen people being resistant to QI is because they are afraid that QI and patient safety interventions are making clinicians more “robotic” by introducing standardization and guidelines. Really though, I cannot think of a field that is trying harder than Patient Safety to get clinicians to recognize and accept themselves as human beings capable of error, empathy, creativity, mistakes, and brilliance.
We are all capable
Of humility. We began our second day in Telluride discussing disclosure of medical errors to patients and families. Recognizing our humanity in this situation is being able to admit failure, learn from it, and be humble enough to accept its consequences. That humility will allow us to tell patients and their… Continue reading
We don’t always know enough to help a patient heal from a disease or illness. In medicine, we don’t always have all the answers.
But other times, we totally do. In fact, there is a group of people called attending physicians who are employed by hospitals to have lots of answers and to provide guidance in times of medical uncertainty.
Today, our conference room in Telluride housed some of the most accomplished nurses, medical students, and young doctors in American healthcare. Many individuals shared stories of hesitating to page on-call physician late at night. Providers and nurses hesitated to page because they did not want to be perceived as incompetent, or perhaps more upsettingly, they did not want to suffer any untoward consequences form waking or disturbing the on-call doc.
This mindset needs to end. Attending physicians and on-call doctors are paid by the hospital to provide guidance and oversee… Continue reading
Academy for Emerging Leaders in Patient Safety – Day 1, June 8, 2015
Sentences that stuck:
After only one day of the “Telluride Experience”, I’ve got 6 pages of handwritten notes and an unending stream of questions and ideas buzzing around my head. Today Dr. Wendy Madigosky asked us to list situations… Continue reading